New/Returning Patient Information Sheet for Adult Patients or Clients
Patient Verification of Sole Coverage and Responsibility for Filing Secondary Insurance Claims
The insurance listed above is the only health insurance I will be using as a third-party payer for my services at CCBT. I understand that if I carry primary and secondary insurance, it will be my responsibility to submit to secondary for reimbursement.
(Your assurance that the information on this sheet is true and your permission to communicate with your insurance, if you are using it.)
I certify that I have truthfully and completely filled out this information form to the best of my ability. I also indicate acceptance of the policies that I have been given and my responsibility for the payment of any incurred fees. If I circled YES to indicate I will be using insurance as a third party payer for the fees charged to me by The Center for Cognitive and Behavioral Therapy (CCBT), I give my permission to CCBT to release Protected Health Information (see HIPAA Policy for definitions) to the insurance company, excluding psychotherapy and/or mental health service notes, including records acquired from all third parties such as physicians or other Mental Health Protected Health Information except mental health service notes from sessions.
The information CCBT has provided me is what they have been given by my insurance company. This information is not a guarantee of payments by my insurance company, and if for any reason my insurance does not pay for these services, I understand that I will be held responsible for the payment.
I understand the Insurance Disclaimer and my responsibility.
Employee Assistance Programs (EAPs) are not regulated in the same way as insurance plans. Patients are required to set up EAP requirements before they are seen and must bring either the paperwork or the authorization number and identifying information regarding the name of their EAP company to their initial visit.
If dates of service are not initially set up under the EAP, they will not be re-billed after the fact.
The EAP may require the patient to fill out paperwork. If The Center for Cognitive and Behavioral Therapy processes the EAP paperwork properly and the EAP does not make payment, the patient is still responsible for the fee(s) for the service dates as expressed in The Patient Services Agreement.
Also, please note that EAP companies may provide the patient with information that is inconsistent with what The Center is provided by the EAP. Depending upon the nature of the EAP company, it is the patient’s responsibility to verify correct information is obtained in advance of services.
REMEMBER, AS THE PATIENT OR RESPONSIBLE PARTY, YOU ARE CHOOSING TO ELECT TO USE AN EAP AND MUST PRE-AUTHORIZE THE VISITS PRIOR TO ANY SERVICE DELIVERY THAT ARE INTENDED TO BE COVERED BY AN EAP.
If yes, provide a copy of any authorization to The Center for Cognitive and Behavioral TherapyAuthorization. If no, you may not be able to utilize your EAP services (see above)
I understand that utilizing my EAP benefit may involve me completing paperwork in order to obtain payment for service.
By signing below, I verify that all information I have provided on this form is accurate:
Recently, the Center for Cognitive and Behavioral Therapy (CCBT) has experienced the impact of higher deductibles, non-paid copays, and co-insurance in patients’ health insurance coverage. CCBT knows you, or your employer, could have elected coverage with a higher deductible than in the past, experienced a change in your copays, or obtained insurance coverage with co-insurance. Sometime, mental health services may be billed at rates different than a regular office visit with a medical specialist. Often you, or your company, makes a decision to choose a high deductible plan to save on the monthly premium. The decision to purchase a specific kind of coverage can lead to your personal responsibility for the service you receive from CCBT for part, or the whole, year.
If you have a deductible to meet, CCBT usually can know the exact amount of the fees for which you are responsible only after your carrier processes a charge for a session and issues an Explanation of Benefits (EOB). CCBT tries to obtain the information on deductibles, copays, and co-insurance prior to your visit, but phone calls and website data involving your carrier can not be relied upon, only the information from the EOB (and then sometimes the carrier changes its mind on those data as well). On the EOB you, and CCBT, are notified of the allowed charge for the session (based on contracts between providers and carriers) and the amount for which you are responsible. The amount for which you are responsible is usually then applied to your deductible. Partly because the amount you will owe is applied to your deductible, CCBT cannot allow you to pay less than this to CCBT.
We realize that the impact of owing personally for a portion of your psychotherapy costs can surprise you. Usually, a new patient/client is informed of the amount they may/will owe ahead of time, but the most accurate information generally cannot be obtained until after the third or fourth session, since carriers take up to 30 days (in the usual case) to process a charge and issue an EOB. By then, you might find you owe several hundred dollars to CCBT due to deductibles, even though CCBT will use the insurance carrier-negotiated rate not the full rate we normally charge.
CCBT wants to be sure you are as aware as possible of the impact on you financially of your insurance product. That’s why you’re being asked to read and sign this form. CCBT wants to try to clarify that you might owe the allowed charges for several, or perhaps many, or even all of your sessions depending on the amount of the deductibles, copays or co-insurance in your health care coverage.
To make it easier for you to manage the balance you might owe due to deductibles, CCBT offers an option to you. Please review the option below and if you elect to use it, initial it, and sign this form. If you elect this auto-charge option, please complete the authorization form attached as well.
Welcome to The Center for Cognitive and Behavioral Therapy of Greater Columbus, Inc. (The Center). This document (the Agreement) contains important information about 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) used for the purpose of treatment, payment, and health care operations. HIPAA requires that you be provided 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 either you provide your signature acknowledging that you have been provided with this information before, or no later than the end of, your first session or that we made an attempt to obtain your signature. Although these documents are long and sometimes complex, it is very important that you read them carefully. You can discuss any questions you have about the procedures with either/or your Mental Health Provider, or one of The Center’s staff. When you sign this document, it will also represent an agreement between you, The Center, and your Mental Health Provider. You may revoke this Agreement in writing at any time. That revocation will be binding unless The Center, or your Mental Health Provider, has taken action in reliance on it; if there are obligations imposed on The Center or your Mental Health Provider by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. You will not be seen for treatment if you do not agree to the terms and conditions found in this Agreement.
MENTAL HEALTH SERVICESMental Health Services, which include, but are not limited to, provision of psychological services, professional counseling, marriage and family therapy, and psychosocial/social work services, are not easily described in general statements. These services vary depending on the personalities of the Mental Health Provider and patient, and the particular problems you are experiencing. There are many different methods that the Mental Health Provider may use to deal with the problems that you hope to address. Mental Health Services are not passive, unlike, for example, having an X-ray done. Instead, they call for a very active effort on your part. Many times, for the Mental Health Services to be effective, you might need to work on things addressed in your appointments, both in the sessions themselves, and outside the sessions.
You might receive services from an Independent Practicing Affiliate (IPA), who is an independent contractor of The Center. If so, The Center may provide the IPA with services including support and administrative services, which is based on a percentage of the fees received on behalf of the IPA, but The Center does not directly oversee the clinical services of the IPA, but the IPA has agreed to follow certain quality measures set by the Center and the IPA. Each IPA is licensed through a State of Ohio board, and complaints about the professional conduct of an IPA should be made to the appropriate board.
Mental Health Services might have benefits and risks. Since Mental Health Services often involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, Mental Health Services have also been shown to have many benefits. Mental Health Services have the potential to lead to better relationships, solutions for specific problems, and significant reductions in feelings of distress. But there are no guarantees about how you might react to the Mental Health Services, nor how beneficial the Mental Health Services will be.
Your first few sessions might involve not only treatment activities, but also an evaluation of your Mental Health Service needs. By the end of the evaluation portion of the Mental Health Services, your Mental Health Provider may be able to offer you some first impressions about what things would be likely be included in your Mental Health Services, including a plan for the Mental Health Services if you decide to continue. You should evaluate this information, and determine if you believe the fit between your Mental Health Provider and you will have a reasonable likelihood of benefiting you. Mental Health Services may involve a large commitment of time, money, and energy, so you should be very careful about the Mental Health Provider you select. If you have questions about the procedures the Mental Health Provider proposes, or eventually uses, you should discuss them with the Mental Health Provider whenever you identify the need to do so. If your doubts persist, you should feel free to obtain a second opinion from another Mental Health Provider and ask your Provider for the names of others from whom you can obtain a second opinion.
Please be advised that The Center has a policy that indicates that if a patient/client is a convicted or registered sex offender, that the patient/client cannot be provided services at any of the offices of The Center. The limitation is due to the following (in no particular order): a) The Center cannot guarantee the safety of clients/patients or staff against sexual assaults, b) The Center’s offices may be within sufficient distance of a school so that children might be at risk should a sex offender who victimizes children be in CCBT’s offices, and/or c) The Center does not include in its services the treatment of sex offenders.
WHO IS THE PATIENT/CLIENT?Under recent rules related to HIPAA, and revisions to the AMA’s coding system (known as CPT codes), as well as State law changes, it has become necessary to be explicit about who is the patient, and who is not the patient. Patient and Client will be used interchangeably throughout this document. The definition impacts on financial responsibility, rights to records access, and other important facets of your rights and responsibilities. The patient is the person who signs the forms assuming financial responsibility, acknowledges receipt of HIPAA policies, and consents to treatment. Under the sections on Minors, and on Couples and Family therapy, there are further explanations of these issues related to treating minors, families, couples, and groups. For instance, someone signing for financial responsibility as a parent is not the patient if the child is designated as the patient. If someone attends a session in which you, or the child, is/are the patient, they are not defined as the patient unless they have specifically signed on as a patient. In that situation, they are a third party entering a session for a specific purpose.
APPOINTMENTS AND SESSIONSNormally, a Mental Health Provider will conduct an evaluation during the first few sessions. During this time, the Mental Health Provider and you can both decide if that specific Provider is likely to provide you with the Mental Health Services in a manner you believe might produce desired outcomes. If further Mental Health Services are begun, the Mental Health Provider usually schedules sessions and appointments that can vary, for example, from 30-minute sessions, to 45 minute sessions, or to 60 minute sessions. However, the length of the session might vary depending on, but not exclusively due to, your particular Mental Health Service needs or for other reasons. Complicating factors may lead to additional complexity in any session (e.g., disruptions to communication, reporting of child abuse, hostility after divorce, etc.). When the complexity is above and beyond the typical expected level for a session, your Mental Health Provider may add a billing code to reflect this increased complexity, which may result in an additional charge. In addition to the length of the sessions, the Mental Health Provider and you may agree on the frequency of those sessions, which might include multiple sessions per week, weekly sessions, bi-weekly sessions, or other frequencies for the schedule of appointments. As with the length of sessions, the frequency of sessions might vary depending on factors such as, but limited to, your individual Mental Health Service needs. The Provider may, solely at the Provider’s discretion, use support staff
to schedule your appointments. Please note that typically insurance companies only pay for one session per week, so you would be responsible for paying for any sessions in a particular week in excess of one session.Once an appointment hour is scheduled, your Mental Health Provider may ask you to pay for it, even if you miss the appointment, unless you provide at least 24 hours advance notice of cancellation. The Mental Health Provider has the option to not charge you, based on the particular reasons surrounding the missed session. It is solely at the discretion of the Mental Health Provider to decide if you will be charged for a missed session that was not cancelled at least 24 hour in advance. It is important to note that insurance companies typically do not provide reimbursement for cancelled sessions, thus you likely will be responsible for the fee personally.
PROFESSIONAL FEESThe Mental Health Providers at The Center charges an hourly fee of $190 for the initial psychological evaluative appointment. Subsequent psychotherapy sessions are billed at the following rates: 30 minute sessions--$80, 45 minute sessions--$120, 60 minute session--$160, increased complexity—an additional $10, crisis sessions--$190, family psychotherapy/couples therapy--$160, psychological testing--$160 per hour, neuropsychological testing--$160 per hour. In addition to weekly appointments, the Mental Health providers may charge $160 per hour for non-session Mental Health Services, though they typically prorate the hourly cost if the work is for periods of less than one hour, often, but not always, using tenths-of-one-hour periods that represent any portion of each six minute period. Other services include report writing, telephone conversations, consulting with other professionals when your case requires such consultations (although if appropriate, your permission will be sought prior to the consultations), preparation of records or treatment summaries, and any other service which is performed by the Mental Health provider.
If your Mental Health provider becomes involved in legal proceedings because of their treatment with you, you will be expected to pay for all of the Mental Health Provider’s professional time, including preparation and transportation costs and travel time, and you agree to pay such amounts, even if the Provider’s involvement is caused by someone other than you. Because of the increased difficulty of providing services in the context of legal involvement, the Mental Health Provider may charge $250 per hour for preparation and attendance, or other activities associated with any legal proceeding. Be advised that should the Mental Health Provider receive a subpoena for your records, or to provide any type of information related to court proceedings, including but not limited to testimony at a deposition, related to your work with the Mental Health Provider, you grant permission to the Mental Health Provider to contact an attorney of the Provider’s choosing, and you grant the Provider permission to share information about your case so that the attorney might provide appropriate legal advice on your situation and the legal issues involved. You will be charged for the time in contact with the attorney, and any legal bills generated, including, but not limited to, filing motions to quash, which are at the option of the Mental Health Provider. The exact amount of the fees involved when contacting an attorney under these circumstances will not be known until the time of the service, so the exact amount may not be disclosed to you until the Mental Health Provider knows the amount. In situations of potential harm to yourself (suicide) or others (injury or homicide – Duty to Protect), or suspected abuse or neglect of a child or elderly person or someone with limited competence, and in instances where the court or administrative agency may subpoena or order records (most commonly in contested divorce actions), the release of confidential materials may be legally required of your therapist. Also, if you report domestic violence, your therapist is required to note that in your clinical record.
CONTACTING YOUR MENTAL HEALTH PROVIDERDue to the varying work schedules of Mental Health Providers at The Center, the Providers may not be immediately available by telephone. While The Center is usually open between 8 AM and 5 PM, it is closed between 11:30 AM and 12:30 PM, and is closed on certain holidays or during calamities. The Mental Health Provider probably will not answer the phone when the Provider is with a patient. Generally speaking, only arranged telephone appointments will ensure contact at a specific time. When the Provider is unavailable, the office telephone is answered by voicemail. On the voicemail, there may be additional information about contacting the Mental Health Provider in case of an emergency, defined as a threat of harm or death to either yourself or someone else. Please be advised that The Center is an outpatient practice and is not a hospital, and cannot guarantee it will provide 24-hour, seven day per week coverage. While you may contact the emergency number listed on the Provider’s voicemail, the Provider may not be able to return the call as quickly as you might need the Provider to call, and therefore you should contact 911 or go to your local emergency room immediately after using any emergency contact procedure that might be provided on the office voicemail. The Mental Health Provider may attempt to contact you based on his/her procedures, but you should always take steps to ensure your safety, or the safety of others, despite any calls placed to the Mental Health Provider. The Center does not provide “on-call” services, meaning that if you call and make a request for either follow-up services from your Provider, or emergency services, The Center does not provide additional Mental Health Providers to deliver Services beyond your own Mental Health Provider. Any coverage by a different Mental Health Provider should be arranged by you and the other Mental Health Provider. Again, your Mental Health Provider is responsible, not The Center, for following-up on requests you might have between appointments for any type of Mental Health Services.
Voicemails are the responsibility of the Mental Health Provider. If you believe you have waited longer than you should for a return call, you can contact The Center, and we will attempt to inform your Provider; but The Center is not responsible for any provider’s obligation to return your calls. Again, The Center cannot guarantee to resolve your concern about messages, even if The Center might try to undertake efforts to resolve your concerns. If the Mental Health Provider will be unavailable for an extended time, the Provider usually will notify you, if such notification is possible, and you should make sure to request from the Provider the procedures to use during the Provider’s absence should unanticipated needs arise. Again, The Center is not responsible for ensuring you have been informed about extended absences of your Provider. Please make any request for “what to do” in writing so there is a record of it for both you and the Provider.
LIMITS ON CONFIDENTIALITYThe law protects the privacy of communications between a patient and a Mental Health Provider. In most situations not involving treatment, payment or health care operations, the Mental Health Provider can only release information about your treatment to others if you sign a written authorization form that is consistent with requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. In most instances only the minimum information necessary to accomplish a specific purpose will be disclosed. Your signature on this Agreement provides consent for those activities, as follows:
--The Mental Health Provider may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, the Provider makes good-faith efforts to avoid revealing the identity of a patient. The other professionals are also legally bound to keep the information confidential. Unless you object in writing, the Provider might not tell you about these consultations unless the Provider decides that it is important to the provision of Mental Health Services to you. The Provider may note consultations in your Clinical Record.
--You should be aware that the Mental Health Provider practices with other mental health professionals at The Center, and that The Center employs administrative and support staff. The Mental Health Provider will typically need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same, or similar, rules of confidentiality. All staff members have received training about protecting your privacy, and have agreed not to release any information outside of the practice without the permission of a professional staff member.
--The Center, and your Mental Health Provider, also may have contracts with other professionals, including but not limited to, attorneys, accountants, billing services, software companies, insurance companies, collection companies, and other entities. As required by HIPAA, The Center, or in some cases the Mental Health Provider as well, if required, has a formal business associate contract with this/these business(es), in which it/they promise to maintain the confidentiality of the data involved, except as specifically allowed in the contract, or as otherwise required or allowed by law.
--Texting, emailing, and even phone conversations using the internet for service, as well as other electronic communications may not be a confidential form of communication if they are unencrypted. If you use any of these ways to communicate with The Center and/or its Providers or administrative staff, please be aware that The Center, and its employees or contractors, cannot guarantee the security of the unencrypted information. If you decide to utilize such unencrypted services, you agree to accept those risks.
--Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
There are some situations where the Mental Health Provider may, or must, 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 or treatment, such information is generally protected by laws that establish a privilege. If privilege applies, the Mental Health Provider cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in, or are contemplating, litigation, you should consult with your attorney to determine whether a court would be likely to order the Mental Health Provider, or The Center, to disclose information. For purposes of this paragraph, litigation, or courts making orders, is meant to include, but not be necessarily limited to, municipal/local courts, state courts, federal courts, as well as administrative legal proceedings. In addition, please be aware that in some state courts in Ohio, judges have ruled that if you place custody of minor children as an issue within a domestic, or juvenile, or probate court proceeding (for example, a divorce, a dissolution, or are contesting the rights to parent when not married), this may constitute a waiver of privilege or expectation of confidentiality for any mental health records about you, including those records that predate your litigation. Also, if you are a party to civil litigation, such as, in a personal injury claim or other type of proceeding, and you, or someone else, makes your mental health or mental distress an issue in the litigation, your privilege may be waived and/or confidentiality might be limited.
--If a government agency is requesting the information for health oversight activities, The Center, or the Mental Health Provider, may be required to provide it to them.
--If a patient files a complaint or lawsuit against The Center, or the Mental Health Provider, The Center or Provider may disclose relevant information regarding that patient in order to defend against the allegation.
--If a patient files a worker’s compensation claim, the patient will, in the typical case, execute a release so that the Mental Health Provider may release information, records or reports relevant to the claim.There are some situations in which the Mental Health Provider may be legally obligated or allowed to take actions which the Mental Health Provider believes are necessary to attempt to protect others from harm; and the Provider may have to reveal some information about a patient’s Mental Health Services. The typical situation in an office like
The Center’s might be:
--If the Provider knows, or might have reason to suspect, that a child under 18 years of age, a developmentally disabled, or physically impaired person either under 21 years of age, or a developmentally disabled or elderly adult, has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably suggests any form of abuse or neglect of the individual, the law requires that the Mental Health Provider file a report with the appropriate government agency. Once such a report is filed, the Provider may be required to provide additional information.
--If the Mental Health Provider reaches an opinion that a patient presents a clear and substantial risk of imminent serious harm to him/herself, a specific individual that can be identified, or to property, the Mental Health Provider may need to disclose certain information that may serve to protect the patient, the specific individual or the property at-risk for harm. The Mental Health Provider may need to disclose that information to appropriate public authorities, and/or the potential victim, and/or take other steps to minimize the risk of harm.
--If a minor is in treatment, with very limited exceptions that are described in the Notice of Privacy Practices or in Ohio’s privilege statute, the Mental Health Provider usually must reveal information about the minor’s Mental Health Services to the minor’s parents. If the minor’s parents are divorced, both parents may have access to information about the minor’s services regardless of custodial arrangements, unless a court-order specifies limitations to a parent’s access to that information. Both parents will also typically be provided with information supplied by the other parent if the child is the only client. If such a court documents exists on the minor, please provide a copy to your Mental Health Provider. This is discussed more later in the Minor section.
If such a situation arises, the Mental Health Provider may make efforts to discuss with you the possible release of confidential information before taking any action, if such a preliminary discussion is possible and appropriate, in the opinion of the Mental Health Provider. The Provider will attempt to limit the disclosure to what is minimally necessary, but understand the Provider might not be able to discuss with you the need to disclose the information, and if not, the Mental Health Provider still may disclose the information.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential limitations, it is important that you and your Mental Health Provider discuss any questions or concerns that you may have now or in the future. The laws and rules governing confidentiality can be quite complex, and neither The Center nor your Mental Health Provider can provide legal advice. In situations where specific advice is required, formal legal advice may be needed, and you should contact your attorney. Should you have questions about these limitations to confidentiality, please try to provide them to the Mental Health Provider in writing in advance of any appointments or contacts.
PROFESSIONAL RECORDSYou should be aware that, pursuant to HIPAA, the Mental Health Provider may keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that are set for treatment, your progress towards those goals, your medical and social history, your treatment history (any past PHI or Mental Health Service Notes received from other providers), reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. With rare exception, if your mental health provider determines for clearly stated treatment reasons that disclosure may have an adverse effect on the patient, in which case you may select another mental provider and the records will be sent to that provider, you may examine and/or receive a copy of your or your child’s Clinical Record if you request them in writing, and the request is signed by you and dated not more than one year from the date it is submitted. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, it is recommended that you initially review them with your Mental Health Provider, or have them forwarded to another Mental Health Provider so you can discuss the contents. Your provider owns these records if they are an IPA, not CCBT, and should your IPA provider leave The Center, he/she will take these records with him/her and your access to those records will be the responsibility of your provider, not CCBT. If your provider is an employee of CCBT, then CCBT will always maintain the records in accordance with applicable records retention requirements.
In most circumstances, The Center may charge a copying fee which varies from year to year, depending on what is allowed under state and federal law. The fee for copying your records is payable in advance, and the fee is typically paid by you, not any third party you wish the records sent to. These amounts may also increase yearly based on data developed by the Ohio Department of Health. If you request your records in an electronic format and we maintain it in that format, then we can send it to you that way. Please be advised that your records may be reviewed by you, or anyone that you release them to, on the premises at The Center, at no charge. The Center will provide support staff to supervise the records review. A request for a records review should be made in advance, received at least 5 business days prior to the need for the records to be reviewed, and the request must be in writing, signed by you or your designee.
The Mental Health Provider also may keep a second set of records, often known as Psychotherapy Notes. Psychotherapy Notes are be defined as those notes, described in what follows, kept by any Mental Health Provider at The Center, regardless of the Provider’s particular discipline or license (for example, Licensed Independent Social Worker, Psychologist, Professional Counselor, Psychiatrist, etc.). These Notes are for the Provider’s own use and are designed to assist the Provider in providing you with adequate treatment. While the contents of Psychotherapy Notes vary from client to client, they may include the contents of information shared during sessions or an analysis of that information. The Psychotherapy Notes may also contain particularly sensitive information that you may reveal to the Mental Health Provider that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept on a form separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they might not be able to receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies may not be able to penalize you in any way for your refusal to sign an authorization for claims payment purposes. Please be advised that the same conditions for copying costs and review as noted earlier in this section apply to copying or reviewing Psychotherapy Notes. Some Mental Health Providers may not create Psychotherapy Notes, and then records of all Protected Health Information would be in your files. In all instances, Ohio law provides a right for a mental health provider to deny a client (or parent if the client is a child) direct access to records when they determine that releasing the records directly to you would have an adverse impact on the client, in which case you can name another mental health professional to which the records will be sent.
PATIENT RIGHTSHIPAA provides for rights with regard to your Clinical Record and disclosures of PHI. These rights may include requesting that the Mental Health Provider, or The Center in some cases, amend your record; requesting restrictions on what information from your PHI is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized or that are not released for treatment, payment or health care purposes (the latter would be available if your Provider utilizes electronic records); the right to file any complaints about the policies and procedures of the Provider or The Center; and the right to a paper copy of the attached Notice form. Your Mental Health Provider would be willing to discuss any of these rights with you.
COUPLES, FAMILY, OR GROUP SERVICES OR WHEN A THIRD PARTY IS PRESENT IN AN INDIVIDUAL SESSIONCouples therapy is distinct from individual therapy which occasionally involves the presence of another person (such as a spouse, partner, family member or friend). When mental health services are delivered to an individual for individual problems, those services are not considered couples therapy even if another person is occasionally present, since the focus of treatment is on the individual patient (AMA, 2012). Couples therapy where both parties are clients is generally not covered by insurance and if you seek couples therapy you agree to pay for the services out of pocket in that case.
In family therapy, all persons are considered patients and all adults must sign in as clients. They may or may not all be given a diagnosis. In that situation, the therapy will be billed as family therapy.
In any mental health service during which more than one person is present, there are specific limitations on the confidentiality rights of, and privilege held by, the various individuals involved. There are issues involving the right to have access to the treatment notes, during or after the treatment or consultation sessions when a legal proceeding is underway—this is the issue of privilege. In Ohio, because more than just the mental health provider and one patient may be in the room, there may be limits to the protection of the information shared in these situations. You should be aware of who holds the privilege and who has the right to confidentiality and who may obtain access to and/or release the records.
Also, there are limits to how effectively the mental health provider can maintain the confidential nature of the information you share in individual psychotherapy, couples therapy, or consultation sessions where more than one person is involved in the mental health sessions. These limits have to do with the presence of people other than you and the mental health provider and the potential that those other people could share information you reveal during the sessions. Also, there may be limits to how effectively the mental health provider can protect that information if you, or someone else, in these sessions requests records or information from these sessions, depending on who, and who is not, a patient.
It is CCBT’s policy to typically attempt to do the following:
• Maintain records of the couples sessions as joint records if all of the persons are patients (that is, all those present have signed a Patient Services Agreement and an acknowledgement of receipt of our HIPAA statement, or an attempt to obtain that acknowledgement). In this situation insurance will typically not reimburse for this type of therapy. In couples therapy, each patient holds a privilege and has the right to confidentiality of the information that patient provides, or which is generated as a record by the therapist in the notes about that patient. Only that person may therefore release, or access, that patient’s own information. It is important to note that any one patient in couples sessions may not release, or access, the information of other patient also present in couples sessions;
• Maintain records of an individual patient’s progress in group treatment or consultations, and in those records not address, by name, any other patient’s comments or behaviors;
• Release only those sections of records from couples or family sessions related to any given patient who executes a release form, and attempt, to the best of any provider’s ability, to redact (black out) information about any patient in a couples or family session who has not signed a release. Note that in family sessions, if there are minors present, typically both parents have access to the minor patient(s) records unless blocked by court order;
• Require only the individual patient in group sessions, wishing to release records of any given session, to sign a release form to authorize the release of confidential information from group sessions regarding only that individual patient;
• Release any patient’s self-generated and written information regardless of the treatment setting, if that individual signs a release form authorizing release of that information; and only under the condition that the to-be-released information (for example, but not exclusively, a client information form, psychological test results) is generated solely by or for that individual;
• Release information in the records about others present in any type of mental health session, if those others are not patients, if and only if the patient signs a release of information; and
• Comply with other laws, court orders, or other requirements listed separately in informed consent forms or the Notice of Privacy Practices form used by The Center, its employees or IPAs that require or may cause the release of confidential information.
If a non-patient is requested by you to attend any type of mental health service, your therapist is responsible to inform the non-patient that a) the non-patient has no right of confidentiality or privilege involving any session attended, and b) only the patient, i.e. you, has a right to confidentiality or privilege of all information related to mental health services since any non-patient who attends a mental health session is not a patient, and that person may not access any records. Your therapist will make any non-patient, who attends any of your mental health sessions, aware that any record related to the provision of mental health services to you is controlled by you, the patient.
All non-patients attending mental health sessions are typically asked to agree not to share the information obtained in the sessions, and it is the responsibility of your therapist to obtain that agreement with a non-patient who might attend a session. You, as the patient, also agree, however, that the mental health provider cannot guarantee that non-patients attending a mental health session will honor that assumption and agreement. It will sometimes be the case that your mental health provider will request you, the patient, sign an additional form regarding the presence of a third party in a session.
Please note that most parents control their children’s confidentiality and privilege, unless there is a court order stating otherwise. So, if the child(ren) is/are the identified patient(s), then both parents have the right to access information provided by the other parent in connection with therapy provided to the child(ren), unless one or both parents are also patients.
MINORSPatients under 18 years of age who are not emancipated, and their parents, should be aware that parents are permitted to examine their child’s treatment records. A special law does, however, allow children between 14 and 18 to independently consent to, and receive up to, 6 sessions of Mental Health Services (provided within a 30-day period), paid for by the minor, and no information about those sessions can be disclosed to anyone without the child’s agreement with some limited exceptions. While privacy in Mental Health Services is often crucial to successful progress, particularly with teenagers, parental involvement is also essential to successful treatment. For teenage children, a Mental Health Provider may have a policy to request an agreement in which the parents agree not to request any of their child’s records. However, regardless of that agreement having been negotiated, except for the exception noted earlier in this paragraph which provides the child with some confidentiality rights, parents are generally entitled to access the information and records derived from the provision of Mental Health Services to minor children and they have the right to revoke their consent to such an agreement. As noted earlier in this Agreement, when parents are divorced, non-custodial or non-residential parents are permitted access to the same information and records as are custodial or residential parents unless expressly limited from that information or those records by an order from a court. All minor children will be advised of these rights, particularly if the parents sign an agreement not to access a child’s records and then later change their minds.
Only parents who have the authority to consent to treatment for a child/adolescent may sign forms and commit to that child’s or adolescent’s receipt of Mental Health Services. Divorced parents or legally separated parents should bring to their first session their divorce decree or other court documents which state who may seek treatment for their child(ren) and who has the responsibility for payment. When the parent who brings the minor to The Center for Mental Health Services is divorced or legally separated, then their signature on this form creates an obligation to pay for Mental Health Services provided to the named minor; unless and only if, the parent provides to The Center information indicating they are not responsible. If such information is provided, Mental Health Services will be delivered only if the party otherwise responsible signs forms creating an obligation to pay AND ONLY IF that other party arranges for payment in accordance with The Center’s policies then in effect.
BILLING AND PAYMENTSYou will be expected to pay for each session at the time it is held, whether you are responsible for the full fee or a co-payment, depending on the status of any Third Party Payment options available to you. The Center may not permit a person receiving Mental Health Services through Providers at The Center to incur an unpaid fee balance which lasts longer than 90 days, where the individual is personally responsible (for example, if you make $25 co-pays but otherwise have your bill paid by a Third Party Payer, the 90 day limit applies to unpaid co-pays, or if you pay cash for your Services, then the 90 day limit applies to the entire fee charges). Payment schedules for other professional services will be agreed to when they are requested.
Provision for the use of automatic payment of amounts owed by a patient, can be found in a separate form.If your account remains unpaid after reasonable attempts have been made by The Center to collect the balance from you, and after the 90 period has run, The Center and your provider may exercise the option of using legal means to secure the payment. The Center and your therapist will have discretion to determine when a reasonable effort has been made, and when to enlist the aid of other legal means. This may involve hiring a collection agency or going through small claims court which will require The Center, and/or the Mental Health Provider, to disclose otherwise confidential information. In most collection situations, the only information that would be released regarding a patient’s Mental Health Services is his/her name, the dates of service and the amount due.
INSURANCE REIMBURSEMENTIn order for you and the Mental Health Provider 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. Your Mental Health Provider will fill out forms and provide you with whatever assistance the Provider can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of the fees. It is very important that you find out exactly what mental health services your insurance policy covers. While The Center will also attempt to determine the coverage available to you, information obtained by The Center cannot be guaranteed to be accurate, since it is obtained typically through phone calls or mail from others, such as Benefits Managers or insurance companies which may not provide accurate information. Ultimately, you are responsible to ensure that any Third Party Payer, whom you believe to be responsible for a portion or all of your bills, makes the payments. Otherwise, you will be responsible for the costs of the Mental Health Services.
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. The Center, or your Mental Health Provider, will provide you with whatever information they might have available, based on experience. You may request that The Center, or your Provider, discuss your coverage and service with an insurance company, but should those discussions occur, you may not receive all relevant information from them since your insurer’s cooperation or accuracy cannot be guaranteed.
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 service 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 Mental Health Services after a certain number of sessions. While much can be accomplished with short-term services, some patients feel that they need more services after insurance benefits end. Some managed-care plans may try to prohibit, or expressly forbid, the Mental Health Provider from continuing to provide services to you once your benefits end. If this is the case, your Provider may try to find another provider who will help you continue your Mental Health Services.
You should also be aware that your contract with your health insurance company requires that The Center, and/or your Mental Health Provider, provide it with information relevant to the services that you are provided. In the typical case, The Center, and/or your Provider, may be required to provide a clinical diagnosis. Sometimes the insurer requires that additional clinical information be provided, such as treatment plans or summaries, or copies of your entire clinical record. When the insurer requires such information to be released, this information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, neither The Center nor your Mental Health Provider has control over what the insurer does with the information once it is in their hands. In some cases, they may share the information with a national medical information databank. You may request, in writing, a copy of forms submitted by your Mental Health Provider to an insurer. By signing this Agreement, you agree that The Center, and your Mental Health Provider, can provide insurer-requested information to your carrier.
Be aware that some carriers require subscribers to respond to requests for additional information, such as verification that the carrier is the sole health insurer for the patient. If you fail to respond to your insurance company’s request for additional information, your claim may be denied and you may become personally responsible for the fees.Based on the level of insurance coverage available to you, you may request that you and your Mental Health Provider discuss what can be expected to be accomplished with the benefits that are available, and what might happen if the benefits run out before you feel ready to end your Mental Health Services. It is important to remember that you always have the right to pay for Mental Health Services yourself to avoid the problems described above unless prohibited by contract between either The Center or your Mental Health Provider and your insurer. Under changes to HIPAA in 2009, you now have the right to elect not to use insurance when seeing a therapist and then no information will be disclosed to your insurance company. You should be aware, however, that you have to make that election prior to each therapy service. You will be charged allowable fees under such circumstances and you must pay those at the time of the request.
SECONDARY INSURANCEPlease be aware that The Center does not submit secondary insurance claims as a general policy of the office. Secondary insurance policies are typically found where coverage is available through two insurance companies, e.g. if both a husband and wife each have coverage for the entire family. If you would like to use a secondary insurance carrier, it will be the responsibility of the patient to submit their own claims forms to request reimbursement for the costs of services. We apologize for any inconvenience this might create.If you are a Medicare Patient and Medicare files a “cross-over” claim with Medicaid, CCBT does not generally accept payments from Medicaid. CCBT will not have billed Medicaid in those cases, and you will still be responsible for your co-payment.
DISCLOSING INFORMATION TO FAMILY MEMBERS, RELATIVES, OR CLOSE FRIENDSUnless you object in writing, by signing below you agree to allow your therapist, if you are incapacitated, in an emergency situation, or are otherwise not available, to contact a family member, a relative, a close friend or any other person you identify, to disclose your personal health information that directly relates to that person’s involvement in your healthcare. This information will be disclosed as necessary only if your therapist determines that it is your best interest based on his or her professional judgment.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during your relationship with The Center and your Mental Health Provider.
If you refuse to sign this form, or fail to provide a signed copy to the Center, you will be refused services by The Center, its employees, and/or its IPAs.
IF COUPLES THERAPY OR FAMILY THERAPY, BOTH PARENTS MUST SIGN THIS FORM. IF YOU ARE NOT THE IDENTIFIED PATIENT FOR BILLING PURPOSES, BUT WILL BE SEEN FOR COUPLES OR FAMILY THERAPY, SIGN BELOW (SEE THE SECTION “COUPLES, FAMILY, OR GROUP SERVICES OR WHEN A THIRD PARTY IS PRESENT IN AN INDIVIDUAL SESSION”)
THIS NOTICE DESCRIBES HOW MENTAL HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care OperationsWe [the therapists at the Center for Cognitive and Behavior Therapy (hereinafter “the Center”), many of whom are independent contractors affiliated with the Center, who for purposes of this Notice will be considered part of the Center] may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes in most instances without your consent under HIPAA, but we will obtain consent in another form for disclosing or receiving information outside of our practice, except as otherwise outlined in this Policy. In all instances we will only disclose the minimum necessary information in order to accomplish the intended purpose. To help clarify these terms, here are some definitions:
• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations”
– Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another therapist.
- Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage, which would include an audit.
- Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
• “Use” applies only to activities within our practice group, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of our practice group, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring AuthorizationWe may use or disclose PHI for purposes outside of treatment, payment, and 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 we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information, including uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI. Examples of disclosures requiring an authorization include disclosures to your partner, your spouse, your children and your legal counsel. Any disclosure involving psychotherapy notes will require your signed authorization , unless we are otherwise allowed or required by law to release them.
III. Uses and Disclosures Requiring Neither Consent nor AuthorizationWe may use or disclose PHI without your consent or authorization as allowed by law, including under the following circumstances:
• Serious Threat to Health or Safety: If we believe that you pose a clear and substantial risk of imminent serious harm, or a clear and present danger, to yourself or another person we may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and/or your family in order to protect against such harm. If you communicate to us an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and we believe you have the intent and ability to carry out the threat, then we may take one or more of the following actions in a timely manner: 1) take steps to hospitalize you on an emergency basis, 2) establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk assessment with another mental health professional, 3) communicate to a law enforcement agency and, if feasible, to the potential victim(s), or victim's parent or guardian if a minor, all of the following information: a) the nature of the threat, b) your identity, and c) the identity of the potential victim(s). We will inform you about these notices and obtain your written consent, if we deem it appropriate under the circumstances.
• Worker’s Compensation: If you file a worker’s compensation claim, we may be required to give your mental health information to relevant parties and officials.
• Felony Reporting: We may be required or allowed to report any felony that you report to us that has been or is being committed.
• For Health Oversight Activities: We may use and disclose PHI if a government agency is requestingthe information for health oversight activities. Some examples could be audits, investigations, or licensure and disciplinary activities conducted by agencies required by law to take specified actions to monitor health care providers, or reporting information to control disease, injury or disability.
• For Specific Governmental Functions: We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, and for national security reasons, such as for protection of the President.
• For Lawsuits and Other Legal Proceedings: If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by law. We cannot provide any information without your (or your personal or 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 us to disclose information. If a patient files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend ourselves.
• Abuse, Neglect, and Domestic Violence: If we know or have reason to suspect that a child under 18 years of age or a mentally retarded, developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the child or developmentally disabled individual under 21, the law requires that we file a report with the appropriate government agency, usually the County Children Services Agency. Once such a report is filed, we may be required to provide additional information. If we have reasonable cause to believe that a developmentally disabled adult, or an elderly adult in an independent living setting or in a nursing home is being abused, neglected, or exploited, the law requires that we report such belief to the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If we know or have reasonable cause to believe that a patient or client has been the victim of domestic violence, we must note that knowledge or belief and the basis for it in the patient’s or client records.
• To Coroners and Medical Examiners: We may disclose PHI to coroners and medical examiners to assist in the identification of a deceased person and to determine a cause of death.
• For Law Enforcement: We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements. • Required by Law. We will disclose health information about you when required to do so by federal, state or local law.
• Public Health Risks. We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, non-accidental physical injuries, reactions to medications or problems with products.
• Information Not Personally Identifiable. We may use or disclose health information about you in a way that does not
personally identify you or reveal who you are. Other uses and disclosures will require your signed authorization.
IV. Patient's Rights and Our Duties
• Right to Request Restrictions and Disclosures–You have the right to request restrictions on certain uses and disclosures of protected health information about you for treatment, payment or health care operations. However, we are not required to agree to a restriction you request, except under certain limited circumstances, and will notify you if that is the case. One right that we may not deny is your right to request that no information be sent to your health care plan if you pay in full for the health care plan service ahead of time. If you select this option then you must request it and you must pay in full each time a service is going to be provided. We will then not send any information to the health care plan for that session unless we are required by law to release this information.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. If your request is reasonable, then we will honor it.
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you for as longas the PHI is maintained in the record, except under some limited circumstances. This does not apply to information created for use in a civil, criminal or administrative action or proceeding. We may charge you reasonable amounts for copies, mailing or associated supplies. We may deny your request to inspect and/or copy your record or parts of your record in certain limited circumstances. If you are denied copies of or access to your PHI, you may ask that our denial be reviewed.
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request, but will note that you made the request. Upon your request, we will discuss with you the details of the amendment process.
• Right to an Accounting – With certain exceptions, you generally have the right to receive an accounting of disclosures of PHI, not including disclosures for treatment, payment or health care operations, for paper records on file for the past six years and for an accounting of disclosures made involving electronic records, including disclosures for treatment, payment or health care operations, for a period of three years. On your request we will discuss with you the details of the accounting process.
• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.Our Duties:
• We are required by law to maintain the privacy of PHI, to provide you with this notice of our legal duties and privacy practices with respect to PHI, and to abide by the terms of this notice.
• We reserve the right to change the privacy policies and practices described in this notice and to make those changes effective for all of the PHI we maintain.
• If we revise our policies and procedures, which we reserve the right to do, we will make available a copy of the revised notice to you on our website, if we maintain one, and one will always be available at our office. You can always request that a paper copy be sent to you by mail. • In the event that we learn that there has been an impermissible use or disclosure of your unsecured PHI, unless there is a low risk that your unsecured PHI has been compromised, we will notify you of this breach.
V. ComplaintsIf you are concerned that we have violated your privacy rights, or you disagree with a decision we make about access to your records, you may file a complaint with us and we’ll consider how best to resolve your complaint. Contact our Privacy Officer, listed below, if you wish to file a complaint with us. In the event that you aren’t satisfied with our response to your complaint, or don’t want to first file a complaint with us, then you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. or to:
Region V, Office for Civil RightsU.S. Department of Health and Human Services233 N. Michigan Ave., Suite 240Chicago, IL 60601. Ph. (312) 886-2359, Fax (312) 886-1807, TDD (312) 353-5693.
There will be no retaliation against you for filing a complaint.
VI. Effective Date:This notice is effective as of September 23, 2013.
VII. Privacy and Security OfficerYou may consult with your own therapist if you have any questions or concerns about anything in this Notice. The Privacy and Security Officer for the Center is Dr. Kevin Arnold, who is located at the Center’s main office at 4624 Sawmill Road, Columbus, OH 43220, Ph. No. 459-4490. You may contact him if you have any questions about any Privacy or Security Policies or if you wish to file a complaint with the practice.
I have received a copy of the Notice of Mental Health Provider Policies and Practices. If I am not the patient, whose name is printed below, I state that I have the authority to sign on behalf of the named patient.
The Center for Cognitive and Behavioral Therapy, Inc. (CCBT) is offering this secure, Health Insurance Portability and Accountability (HIPAA) compliant communication tool as a courtesy to our patients and/or their parents. (HIPAA is a federal law which provides protection to your health information) It is an optional service, although we strongly recommend that you use it, and we reserve the right to suspend or terminate it at any time. We will alert you to any changes as promptly as possible. This form is intended to inform you of the facts and risks surrounding the use of the web portal. By signing below, you confirm that you have read, understand, and agree to accept the risks and comply with our procedures and guidelines for using the Patient Portal.
Privacy and SecurityThe web portal or webpage has a secure tunnel connection with our clinic that uses encryption to keep unauthorized persons from being able to access and read your health information or your communications to us. To help insure that the tunnel remains secure, we need to have your current (private) email address and be informed if it ever changes. Keep your portal user ID and password secure so that only you, or someone authorized by you, can gain access to patient information. If you think someone has learned or otherwise obtained your password, immediately go to the portal site and change it. Also, be careful where you access the portal, since by using an employer computer or using a computer in a public place you may be exposing and unintentionally compromising your information and your e-mail ID and/or your password.
Your email address will be considered confidential by us and we will use our best efforts to protect it. We will never share this information with any third party, unless we are allowed or required by law to do so. If you have communicated with us over email through an unsecured means (e.g., contacting us on our website via that email link), you received information that it was not secure and agreed to accept that risk. We would never share your email from that communication either with any third party, except allowed or required by law to do so.
All access to our internal network and electronic health records (EHR) is password protected. Our staff is instructed to logoff their workstations when not physically present. Additionally, in compliance with HIPAA guidelines, our EHR automatically logs the user out after a period of inactivity. When providers access the EHR using CCBT laptops, the data from the laptop to WIFI connections is protected by a virtual private network program.
Similar to phone communications, messages may be read and addressed by different CCBT staff. When your provider is ill or on vacation, your emails may be addressed by an administrative staff member or other provider, depending on the content of the communication.
IF YOU WISH TO HAVE ELECTRONIC SERVICES (TELE-BEHAVIORAL HEALTH) AS AN OPTION, PLEASE INITIAL HERE TO ELECT IT AS AN OPTION, THEN READ THEN SIGN THIS FORM.
Electronic Service Delivery is defined as mental health therapy in any form offered or rendered primarily by electronic or technology assisted approaches when the mental health therapist and the client are not located in the same place during delivery of services. While working with your therapist at CCBT you will always have the opportunity to ask any questions that you have about the therapy, electronic communications in general, and other issues involving your therapy. Your therapist will also assess your ability to handle computers and the internet, so that you and he or she may work in this way.
As a client receiving mental health services through electronic service delivery methods, you should understand:
1) This service is provided by technology (including but not limited to video, phone, apps, text, and email) and may or may not involve direct, face to face, communication. There are benefits and limitations to these types of services. You will need access to, and familiarity with, the appropriate technology to participate in the service provided. Exchange of information may not be direct and any paperwork exchanged will likely be exchanged through electronic means or through postal delivery. Your therapist will assess whether or not therapy through means of electronic service delivery is appropriate for addressing your issues and whether or not you have the knowledge and skills to use the technology involved.
2) As a therapist licensed in Ohio, your therapist may only deliver services to residents or people located in Ohio. If you plan on leaving Ohio for any length of time in the future, please let your therapist know as soon as possible so that you and he or she can make proper arrangements for future work or referrals, as appropriate. If you are going to be out of state during therapy then your therapist will have to comply with the licensing laws of the state where you will be located.
3) If a need for direct, face to face services arises, it is your responsibility to contact providers in your area, or to contact this office for a face to face appointment. You understand that an opening may not be immediately available.
4) You may decline any electronic service delivery service at any time without jeopardizing your access to future care, services, and benefits.
5) These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over the internet or through other electronic services that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. Your therapist and you will regularly reassess the appropriateness of continuing to deliver services through the use of technology. When using these services you agree to accept the risks involved with the unencrypted exchange of information, if it is provided in that way.
6) Your therapist will need to verify your identity in a face to face meeting, which may be via video/audio electronically and then at subsequent sessions. At the initial session you and your therapist will address imposter concerns. You should be aware that misunderstandings are possible with telephone, text-based modalities (e.g., email), and real-time internet chat, since non-verbal cues are relatively lacking. Even with video chat software, since bandwidth may be limited and images may lack detail, misunderstandings may occur. Your therapist is an observer of human behavior. He or she will gather information from body language, vocal inflection, eye contact, and other non-verbal cues. Cultural differences and how they affect non-verbal cues may also be involved and your therapist will assess whether or not this type of therapy is appropriate for your cultural experiences, your environment and your therapeutic needs. If work is being done with families or groups with different levels of technology competence, power dynamics will be acknowledged. Please let your therapist know if you have any type of audio/visual or cognitive impairment prior to beginning therapy. If you have never engaged in online counseling, you need to have patience with the process and request clarification if you believe that you are not being understood by your therapist or you do not understand something that your therapist says. He or she will regularly review whether or not electronic service delivery is meeting the goals of therapy. Your therapist will also discuss with you how to handle disruptions in services and will discuss with you all methods of delivering services that are compliant with commonly accepted standards of technology safety and security at the time at which
7) In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means:
a) In emergency situations: If it is an imminent situation that requires face-to-face contact call 911 or go to the nearest emergency room. If it can be managed over the phone, you can call your therapist but if your therapist does not respond immediately or within a short period of time, you should contact local emergency services (for instance, call 911 or your local emergency room, in Columbus you may call Netcare Access at (614) 276-2273 Also, other local hotline crisis phone numbers may be available to call and you can check on the internet to find those.
b) Should service be disrupted: Try to regain contact using the same medium. If that does not work, attempt to make contact using text or e-mail. Your therapist will also make every effort to regain contact. If service is disrupted during a therapy session before the pre-agreed time frame has ended, you will have the opportunity to use the remaining time as soon as contact is made. If contact is not re-established within one hour, you will have the choice to end the session and be charged a pro- rated amount or allowed to schedule an additional session to use the remaining
c) For other communication: Your therapist and you may agree to communicate via a phone call or video conferencing, e-mail, text, fax, or mailed letters.
8) The potential benefits of online counseling include flexibility in scheduling and allowing you to engage in counseling outside of the office, which eliminates issues like transportation and other psycho-social barriers that might make it difficult for you to handle in a traditional office setting. The provision of online counseling may include risks related to the technology used, the distance between you and your therapist, and issues related to timeliness. For example, the potential risk of confidentiality may pertain to your accessing the internet from public locations. You should consider the visibility of your screen and being overheard when in public settings. It is recommended that you be in a private setting when engaging in online counseling. You should also always use strong passwords to protect any information shared with your therapist. Never use a work computer for therapy as your employer may have access to the information shared in electronic communications, Be cautious when using a shared network with others.
9) Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than it is in person. You are responsible for confidentiality in your own environment, including securing your hardware, internet access points, chat software, email, and passwords. Please develop passwords that are appropriate and strong and not use auto-fill for user names or passwords. Although your therapist will take steps to protect your information, he or she will have policies in effect to notify you of a breach of any of your confidential information which is required to be reported to you. (9) Your therapist may utilize alternative means of communication in the following circumstances: if you do not respond to text, your therapist may call. If you do not respond to a call, your therapist may follow up with text or e-mail. If you do not respond to a call, text, or e-mail, your therapist may follow up with a mailed letter. In case of emergency (or concerns over your welfare), your therapist may contact your emergency contact if you have provided one.
10) Your therapist will attempt to respond to communications and routine messages within 48 hours if he or she is available.
11) Most insurance companies in Ohio only currently reimburse for face to face in person therapy sessions, so there may not be insurance coverage for therapy sessions delivered through technology. You should check with your insurance company to determine if they will reimburse you for electronic service delivery
12) You need to take the following precautions to ensure that your communications are directed only to your therapist or other individuals: Ensure that you use the correct e-mail address, telephone number, skype or online name, fax number, and physical address to contact the appropriate individuals. Only leave voice messages after ensuring that the correct phone number was dialed and the voicemail the introduction identifies the correct individual.
13) Your communications exchanged with your therapist, if capable of being put into written form, will be stored in the following manner: e-mails, texts, and other electronic communication relevant to treatment well be printed and kept in your file. Mailed letters and documents will also be kept in your file. Notes outlining electronic service delivery treatment sessions will be written and kept in your file. Your file will be kept in a locked file cabinet or stored electronically and will be accessible only by those who require or are allowed access and will be available to you or someone named by you for the length of time required under Ohio law. Your therapist will not record sessions without first discussing it with you and obtaining your permission to do that. Please see your therapists regular Informed Consent form for information on access to your records and who else will have access to
14) The laws, ethics and professional standards that apply to in person therapeutic services also apply to services delivered by electronic means. This document does not replace other agreements, contracts, or documentation of informed consent covering other issues. If you want to license information on your therapist you can mfind it at one of the licensing board websites. Psychology Board statutes, rules and other helpful information may be found at www.psychology.ohio.gov, the Counselor, Social Worker & Marriage and Family Therapist Board's website may be found at www.cswmft.ohio.gov, the Chemical Dependency Professionals Board's website may be found at www.ocdp.ohio.gov, and the Ohio State Medical Board's website may be Acknowledgment of Informed Consent to Treatment via Electronic Service Delivery
You voluntarily agree to receive mental health assessment, care, treatment, or services and authorize your therapist to provide such care, treatment or services as are considered necessary and advisable via electronic service delivery means. By signing this Electronic Service Delivery Informed Consent, you, the undersigned client, acknowledge that you have both read and understood all the terms and information contained herein and you agree to be bound by the provisions in this agreement. Ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you. If a minor is the client, you are signing on behalf of the minor as the authorized parent/guardian. (Information on Minor rights will be shared with the minor) You also acknowledge that you have received a copy of the regular Informed Consent and Notice of Privacy Practices for CCBT.
Parent(s) or Guardian Signature (for minor child or children or disabled adults)
Signature of Client or Legal Guardian
This document contains important information about our decision (yours and mine) to engage in therapy which will take place in public places. This is treatment that occurs in natural environments where the treatment is appropriate and consistent with treatment goals. Examples include behavioral therapy in public places which may be used for a) exposure therapy and/or b) modification of conditioned reactions (e.g. developing a positive response to situations which previously resulted in a negative experience). Please read this carefully and let me know if you have any questions. When you sign this document, it will be an agreement between us. This form applies to you, me, as your individual therapist, and the practice.
Decision to Meet In Public SpacesWe’ve agreed to meet in person in public spaces for some or all future sessions. If there is a change in circumstances, however, I may require that we meet via telehealth or in my office. If you have concerns about switching the therapy to a different setting, please let me know and we can discuss it.
Risks of Opting for Services in Public Spaces and Release of LiabilityYou understand that by agreeing to engage in therapy in public spaces that I cannot guarantee confidentiality nor the safety of the environment. Examples could be that you might be exposed to allergens or inclement weather or even contact with contaminated surfaces or people. Therefore, you are assuming the risk of exposure to the various elements and possible health hazards as well as to the possible risks to confidentiality and you agree to release and hold harmless me and the practice from any and all liability associated with such risks.
Please Initial after each Statement
I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.
Commitment to Minimize ExposureMy practice and I have taken steps to reduce the risk of spreading the virus, such as with mask wearing and practicing safe distancing. However, neither I nor the practice have control over public places. Please let me know if you have questions about these efforts.
If You or I Are SickYou understand that I am committed to keeping you, me, and all of our families safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the appointment immediately.
If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions.
Your Confidentiality in the Case of InfectionIf you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in contact with me. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details of the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.
Informed ConsentThis agreement supplements to the general informed consent/business agreement that we agreed to at the start of our work together.
Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You many add a note or details in the space next to the concerns checked. (For a child, mark any of these and then complete the “Child Checklist of Characteristics.”)